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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201157
Report Date: 06/27/2022
Date Signed: 06/27/2022 11:04:21 AM

Document Has Been Signed on 06/27/2022 11:04 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MITC EAST BAYFACILITY NUMBER:
019201157
ADMINISTRATOR:MENDOZA, GABRIELFACILITY TYPE:
775
ADDRESS:2192 E 14TH STTELEPHONE:
(408) 427-7119
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 70CENSUS: 0DATE:
06/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Program Director, Gabriel MendozaTIME COMPLETED:
11:10 AM
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On 06/27/2022 at 10:45 AM, while at the facility for Prelicensing, Licensing Program Analyst (LPA) L. Holmes completed a Component III presentation with Program Director (PD), Gabriel Mendoza.


PD and two additional staff were present, LPA discussed the COVID-19 infection control requirements, the importance of attending the informational calls, understanding the updated guidelines and printing the provider information notices (PINS) for clients, authorized representatives and staff so that the facility maintains awareness and updates for compliancy with the Title 22 regulations.

-Component III completed.

Exit interview conducted and a copy of this report provided to Program Director, Gabriel Mendoza.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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